Optimized Chronic Care for Smokers: Developing and Implementing Integrated Clinical and Systems Interventions in Primary Care

总体汇总 吸烟是导致癌症死亡的主要可预防原因。然而，医疗保健系统并没有 意识到他们的潜力，以减少吸烟率;太少的吸烟患者提供和使用 吸烟治疗和这种治疗不够有效。该项目解决了这些关键问题。 通过开发一种特别有效的综合慢性护理吸烟治疗， 通过4个独立项目和3个核心，了解医疗保健中的吸烟流行率。该项目将平衡 通过强大的，创新的研究方法，如多阶段优化的内部和外部有效性 战略（MOST），同时也使用现实世界的初级保健诊所，病人和工作人员，并使用RE-AIM 加强其公共卫生影响的框架。采用析因设计，戒烟筛查项目将 评估了608名愿意戒烟的吸烟者的四个实验因素，首次确定， 干预策略（准备药物、扩展药物和咨询方式）结合联合收割机， 产生特别有效的优化伐尼克兰和尼古丁替代疗法（C-NRT） 治疗包基于成本和1年的禁欲。卫生系统干预项目 将首次使用析因实验来评估旨在增加使用的三种干预措施， 停止治疗（即，达到）2年以上的1664名吸烟者最初不愿意戒烟：1）金钱奖励 使用吸烟治疗，2）基于电子健康记录（EHR）的自动定制外展，以及3） 护理管理。将开发一个优化的到达干预包， 最初不愿意戒烟的吸烟者使用伐尼克兰和C-NRT戒烟治疗的比率。优化 护理项目将包括两项随机对照试验（RCT），评估优化的停药 和Reach干预包在停止和Reach项目中开发。一项RCT将比较 优化戒烟治疗与标准治疗（医生和戒烟热线转诊）对1年戒烟的影响 600名吸烟者愿意戒烟第二项RCT将比较优化达到和停止的组合 900名最初吸烟者的干预与标准治疗对戒烟治疗使用和1年戒烟的影响 不愿意放弃。实施项目将评估覆盖范围、实施（保真度、适应性、 与有效性的关系），患者代表性，以及其他3种干预措施的维持 在患者、员工、诊所和系统层面使用EHR、调查、定性和观察数据的项目。这 计划项目将得到行政与后勤、数据分析和优化核心的支持， 共享资源：通过增强的EHR协作医疗系统和招聘。这个程序 该项目将开发一种针对医疗保健的慢性护理吸烟治疗，包括优化覆盖范围， 容易实施和传播的戒烟干预措施， 和戒烟治疗的有效性，最终降低吸烟率和癌症死亡率。

Overall Summary Tobacco smoking is the leading preventable cause of cancer death. However, healthcare systems have not realized their potential to reduce smoking prevalence; far too few patients who smoke are offered and use smoking treatments and such treatments are insufficiently effective. This Program Project addresses these key obstacles by developing an especially effective comprehensive chronic care smoking treatment to reduce smoking prevalence in healthcare via 4 individual projects and 3 cores. This Program Project will balance internal and external validity via powerful, innovative research methods such as the Multiphase Optimization Strategy (MOST) while also using real-world primary care clinics, patients, and staff, and using the RE-AIM framework to enhance its public health impact. Using a factorial design, the Cessation Screening Project will evaluate four experimental factors in 608 smokers willing to quit to determine, for the first time, which intervention strategies (Preparation Medication, Extended Medication, and Counseling Modality) combine to produce especially effective Optimized Varenicline and Combination Nicotine Replacement Therapy (C-NRT) Treatment Packages based on cost and 1-year abstinence. The Health System Reach Interventions Project will, for the first time, use a factorial experiment to evaluate three interventions intended to increase the use of cessation treatments (i.e., reach) over 2 years in 1664 smokers initially unwilling to quit: 1) Monetary Incentives to Use Smoking Treatment, 2) Electronic Health Record (EHR) Based Automated Tailored Outreach, and 3) Care Management. An Optimized Reach Intervention Package will be developed that produces especially high rates of varenicline and C-NRT cessation treatment use by smokers initially unwilling to quit. The Optimized Care Project will comprise two randomized controlled trials (RCTs) that evaluate the Optimized Cessation and Reach Intervention Packages developed in the Cessation and Reach Projects. One RCT will compare Optimized Cessation Treatment versus Standard Care (physician & quitline referral) on 1-year abstinence in 600 smokers willing to quit. The second RCT will compare combined Optimized Reach and Cessation Interventions versus Standard Care on cessation treatment use and 1-year abstinence in 900 smokers initially unwilling to quit. The Implementation Project will assess the reach, implementation (fidelity, adaptation, relation with effectiveness), patient representativeness, and maintenance of interventions in the other 3 projects using EHR, survey, qualitative, and observational data at patient, staff, clinic, and system levels. This Program Project will be supported by Administration & Logistics, Data Analysis, and Optimization Cores and by shared resources: collaborating healthcare systems and recruitment via an enhanced EHR. This Program Project will develop a chronic care smoking treatment for healthcare that includes optimized reach and cessation interventions that can be readily implemented and disseminated and that markedly increase the use and effectiveness of cessation treatment, ultimately reducing smoking prevalence and cancer deaths.